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University of PennsylvaniaScholarlyCommons
Miscellaneous Papers Miscellaneous Papers
1-1-2001
Critical Care Nursing of Infants and ChildrenMartha A. Q. CurleyUniversity of Pennsylvania, [email protected]
Patricia A. Moloney-HarmonThe Children's Hospital at Sinai
Copyright by the author. Reprinted from Critical Care Nursing of Infants and Children, Martha A.Q. Curley and Patricia A. Moloney-Harmon(Editors), (Philadelphia: W.B. Saunders Co., 2001), 1,128 pages.
NOTE: At the time of publication, the author, Martha Curley was affiliated with the Children's Hospital of Boston. Currently, she is a faculty memberin the School of Nursing at the University of Pennsylvania.
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/miscellaneous_papers/4For more information, please contact [email protected].
Please Note: The full version of this book and all of its chapters (below) can be found on ScholarlyCommons (from the University of Pennsylvania) at http://repository.upenn.edu/miscellaneous_papers/4/ Information page in ScholarlyCommons Full book front.pdf - Front Matter, Contributors, Forward, Preface, Acknowledgements, and Contents Chapter 1.pdf - The Essence of Pediatric Critical Care Nursing Chapter 2.pdf - Caring Practices: Providing Developmentally Supportive Care Chapter_3.pdf - Caring Practices: The Impact of the Critical Care Experience on the Family Chapter_4.pdf - Leadership in Pediatric Critical Care Chapter 5.pdf - Facilitation of Learning Chapter_6.pdf - Advocacy and Moral Agency: A Road Map for Navigating Ethical Issues in Pediatric Critical Care Chapter_7.pdf - Tissue Perfusion Chapter 8.pdf - Oxygenation and Ventilation Chapter_9.pdf - Acid Base Balance Chapter 10.pdf - Intracranial Dynamics Chapter 11.pdf - Fluid and Electrolyte Regulation Chapter 12.pdf - Nutrition Support Chapter 13.pdf - Clinical Pharmacology Chapter_14.pdf - Thermal Regulation Chapter_15.pdf - Host Defenses Chapter 16.pdf - Skin Integrity Chapter_17.pdf - Caring Practices: Providing Comfort Chapter 18.pdf - Cardiovascular Critical Care Problems Chapter 19.pdf - Pulmonary Critical Care Problems Chapter 20.pdf - Neurologic Critical Care Problems Chapter 21.pdf - Renal Critical Care Problems Chapter 22.pdf - Gastrointestinal Critical Care Problems Chapter_23.pdf - Endocrine Critical Care Problems Chapter_24.pdf - Hematologic Critical Care Problems Chapter_25.pdf - Oncologic Critical Care Problems Chapter_26.pdf - Organ Transplantation Chapter 27.pdf - Shock Chapter_28.pdf - Trauma Chapter_29.pdf - Thermal Injury Chapter 30.pdf - Toxic Ingestions Chapter_31.pdf - Resuscitation and Transport of Infants and Children back.pdf - Appendices and Index
NomotIram ~ Red Flags of Respiratory DistressI I I
Hei(hl F", children of SAIf:i~1
Tachypneacm~m normal hei,hl
m2 ~ Mechanics of breathingfor wei,h!
180 80 Retractions90 1.30 160 70 Nasal flaring80 1.20 m70 1.10 60 Head bobbing
90 1.00 50 Grunting on exhalation85 60 10080 50 .90 90 40 Air entry: stridor/wheezing75 80 Change in breath sounds70 .80 7040 30 Prolonged inspiratory time-stridor65 .70 6060
25 Prolonged expiratory time-wheezing30 .60 50
55 .55 45 20.50 40 Late signs
50 35 15 Skin color changes-dusky/cyanotic20 .45 3045 Apnea/irregular respirations.40 2540 15 .35 0.5
10 Change in level of consciousness/activity20 9.0 Bradycardia
90 35 18 8.0.30 16 7.00.480 10 14 6.0
~30 9 .25 12 Red Flags of Cardiovascular Collapse
70 28 8 5.026 0.3 107 9 4.0 Tachycardia
60 24 6 .20 8
22 7 3.0Altered perfusion
20 5 0.2 6 Skin50 19 2.5 Prolonged capillary refill4 .15 5
18 Surface 2.0 Increased core to skin temperature gradient17 area 440 16 3 in Brain
15 W.i,~t square 31.5 Altered level of consciousness/activity
14 In meMpounds .10 Decreased response to parents13
2 0.1 1.0 "Worried" appearance30 12
KidneysAlternative <Mosteller's formula), Decrea~ed urine output
Sulface area (m2) =YHeight (em) x Weight (kg)Decrease in pulse quality
3600Late signs
Body surface area nomogram and equation. (Data from Briars Decreased response to painGL. Bailey BJ: Surface area estimation: pocket calculator v nomo- Flaccid tonegram, Arch Dis Child 70:246-247, 1994.) Hypotension
Bradycardia
Modified Coma Score for Infants/Glasgow Coma Score
Modified Coma Score for Infants Glasgow Coma Score
Best Response Score Activity Best Response Score
~: Eye Opening
rT,.? .
lei.Verbal,.i,l'~~,'
..~.~~~.
~ Motor
SpontaneousTo speechTo painNoneCoos and babblesIrritable criesCries to painMoans to painNoneNormal spontaneous movementsWithdraws to touchWithdraws to painAbnormal flexionAbnormal extensionNoneTotal Score
432I54
32I654
32I
3-15
Eye Opening
Verbal
Motor
SpontaneousTo speechTo painNoneOrientedConfused conversationInappropriate wordsIncomprehensible soundsNoneObeysLocalizesWithdrawsAbnormal flexionExtendsNoneTotal Score
432I5432I65432I
3-15
I'~t Modified Coma Score for Infants from Rogers Me: Textbook (4pediatric imensive care. Baltimore. 1992. Williams & Wilkins.liOlasgow Coma Score from Jennett B. Bond M: Assessment of outcome after severe brain damage: a practical scalc. Lancet 1:480-485. 1975.,
Pediatric Predicted Weight. BSA. and Equipment Needs
Age
Birth 6 mo 1 yr 2 yr 3 yr 4 yr 5 yr 6 yr 8 yr 10 yr 12 yr 14 yr Adult
;Weight (kg) 3.5 7 10 12 14 16 18 20 25 30 40 50 70,: Body surface 0.25 0.38 0.49 0.55 0.64 0.74 0.76 0.82 0.95 1.18 1.34 1.5 1.73
area (m')· Endotracheal 3-3.5 3-5.4 4 4.5 4.5 5 5 5.5 6 6.5 7 7 7.5-8
tube size (mm)Teeth to mid- 9 11 12 13 14 14 15 15 16 17 18 20 20
trachea (em)Nares to mid- 10 12 14 15 16 17 18 19 20 21 22 23 24
trachea (em)Suction catheter 6-8 8 8 8-10 8-10 10 10 10 10-12 12 12 12 12-14
size (Fr)~. Nasogastric 5-6 8 8-10 10 10-12 12 12 14 14-18 18 18 18 18
tube size (Fr);:Urinary catheter 5-6 8 8-10 10 10 10-12 10-12 10-12 12 12 12 12-16 16
size (Fr)
Normal Heart. Respiratory Rates. and Blood Pressures in Children
Normal Heart Rates in Children Normal Blood Pressures in ChildrenNormal Respiratory
Awake Heart Rate Sleeping Heart Rate Rates in Children Systolic Pressure Diastolic Pressure;':'Age (beats/min) (beats/min) (breaths/min) (mmHg) (mmHg)
. Neonate 100-180 80-160 30-60 60-90 20-60·-Infant 100- 160 75-160 30-60 87-105 53-66: Toddler 80-110 60-90 24-40 95-105 53-66
Preschooler 70-110 60-90 22-34 95-110 56-70· School-age child 65-110 60-90 18-30 97-112 57-71
Adolescent 60-90 50-90 12-16 112-128 66-80
'-Estimated systolic blood pressure norms (for infants and children beyond I year of age): 50th percentile systolic blood pressure = 90 mmHg + (2 X age· in years): 5th percentile systolic blood pressure = 70 mmHg + (2 x age in years).
Maintenance Fluid and CaloricRequirements
Body Weight Maintenance Formula
Weight
,:.Neonate «72 hr)"0-10 kg[U-20 kg-"',
i~21-20 kg
~
nf.8octy Surface Area Formula'>1500 ml/m' body surface area/day
~:_,
Formula
60-100 ml/kg100 mllkg1000 ml for first 10 kg +
50 ml/kg for kg 11-201500 ml for tirst 20 kg +
25 ml/kg for kg 21-30
~_lnHnsible Water Lossesf-300 ml/m' body surface area
if Daily Caloric Requirements by Age>lnfant
'.> 1-2 yr (Toddler/Preschooler)":.School-age"10-12 yr
100- 150 Calories/kg90-100 Calories/kg70-80 Calories/kg50-60 Calories/kg
I
CRITICALCARENURSINGojlnfants and Children
SECOND EDITION
TICAL
NURSojlnfants and Children
Second Edition
MARTHA A.Q. CURLEY, RN, PhD, CCNS, FAANCritical Care Clinical Nurse SpecialistMultidisciplinary Intensive Care Unit
Children's Hospital BostonBoston, Massachusetts
PATRICIA A. MOLONEy-HARMON, RN, MS, CCNS, CCRNAdvanced Practice Nurse/Clinical Nurse Specialist
The Children's Hospital at SinaiBaltimore, Maryland
W.B. SAUNDERS COMPANYA Harcourt Health Sciences Company
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Copyright © 2001 by W.B. Saunders Company
NOTICE
Pharmacology is an ever-changing field. Standard safety precautions must be followed, but as new research andclinical experience broaden our knowledge. changes in treatment and drug therapy may become necessary orappropriate. Readers are advised to check the most current product information provided by the manufacturer ofeach drug to be administered to verify the recommended dose, the method and duration of administration, andcontraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge of thepatient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the editorassume any liability for any injury and/or damage to persons or property arising from this publication.
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Printed in the United States of America
Library of Congress Cataloging in Publication Data
Critical care nursing of infants and children / [edited by] Martha A.Q. Curley. PatriciaMoloney-Harmon.-2nd ed.
p.; cm.Includes bibliographical references and index.ISBN 0-7216-9031-9
I. Pediatric intensive care. 2. Pediatric nursing. 3. Intensive care nursing. I. Curley,Martha A.Q., 1952- II. Moloney-HarnlOn, Pat.
[DNLM: I. Critical Care-Child. 2. Critical Care-Infant. 3. PediatricNursing-methods. 4. Critical Illness-nursing. 5. Intensive Care Units,Pediatric-standards. WY 159 C934 200IJRJ370.C87 2001610.73'62-dc21 00-067021
01 02 03 04 05 GW/MV 9 8 7 6 5 4 3 2
To the patients and familieswe've had the privilege to come to know.
To my nursing colleagues:
It's NOT Invisible
Today, I saw you . ..
Make room for more than 20 family members at the bedside all at once,so that everyone could be together with Billy one last time.
Ask Billy:~ grandfather to plug the extension cord in; you knew heneeded to do something-anything.
Give options to Billy:~ parents about "being there" during resuscitation attempts and helpthem choose words to talk with him, considering he was only 8 years old.
Speak very softly to Stephen while removing the tape from his eyelidsonly to find his pupils blown and unequal . ... you didn't even changeyour facial expression-you didn't want to upset mom . .. , not any more... not just then.
Ask Stephen '.I mom what she was thinking as she stood near his bedlooking out the window just before support was withdrawn. ... "He wasalways very quiet, but I knew something was wrong; I should have taken him to the hospitalbut, he didn't want to go". .. , wipe your tears as you listened and convincingly say that shedid the best that she could.
Take a deep breath before you spoke up at team conference . .. "We ought to be more vigilantaboUl the conversations we hold at the bedside-we don't know what Stephen s level ofconsciousness is under the sedation and chemical paralyzing agents". .. , whisper in Stephen:~
ear that the new ventilator might be scary because of the noise it made, then dly his tears.
Take the time to sit with Rachel's mom while others resuscitated herdaughtel; your patient, because you knew she was alone~her husband was on his way in.
Resuscitate Rachel because you knew that Rachel's mom needed yourcolleague right then.
Care enough to take the time to "orchestrate" death to make theworst-thing-in-the-world-anyone-could-ever-experience , a little more tolerable.
It may be very hard for others to hear what we do . .. it can just be so sad. We eventually stoptelling them. Eventually, we might think that our caring becomes invisible. But, it is not invisiblenot to Billy, not to Stephen, not to Rachel, or their parents, or to one anothet:
MARTHA A.Q. CURLEY, RN, PhD, CCNS, FAAN
CONTRIBUTORSPATRICIA ADAMS, RN, BSN, MSStaff ursePediatric Critical CareCCN IncorporatedLaurel, Maryland
Chapter 28: Trauma
CHRISTINE ANGELETTI, RN, BSNPediatric ICU Nurse CoordinatorPediatric Intensive Care UnitChildren's Hospital of PittsburghPittsburgh, Pennsylvania
Chapter 26: Organ Transplantation
ANNETTE L. BAKER, MSN, RN, PNPPediatric Nurse PractitionerCardiovascular ProgramChildren's Hospital BostonBoston, Massachusetts
Chapter 18: Cardiovascular Critical Care Problems
DEBBIE BRINKER, RN, MS, CCNS, CCRNPICU Clinical Nurse SpecialistPediatric Intensive Care UnitDeaconess Medical CenterSpokane, Washington
Chapter 24: Hematologic Critical Care Problems
JANET CRAIG, RN, MS, CS, CCRNPediatric Nurse PractitionerPediatric CardiologyPrimary Children's Medical CenterSalt Lake City, Utah
Chapter 7: Tissue PeifusionChapter 18: Cardiovascular Critical Care Problems
MARTHA A.Q. CURLEY, RN, PHD, CCNS, FAANClinical Nurse SpecialistMultidisciplinary ICUChildren's Hospital BostonBoston, Massachusetts
Chapter I: The Essence of Pediatric CriticalCare Nursing
Chapter 3: Caring Practices: The Impact ofthe Critical Care Experience on the Family
Chapter 8: Oxygenation and VentilationChapter 19: Pulmonary Critical Care ProblemsChapter 27: Shock
SANDRA J. CZERWINSKI, RN, MSAdministrative DirectorDepartment of NursingAll Children's HospitalSI. Petersburg, Florida
Chapter 5: Facilitation of Learning
ix
CATHY H. DICHTER, RN, PHD, FCCMClinical Nurse SpecialistPediatric Cri tical Care CenterClarian Health Partners, Inc.Riley Hospital for ChildrenIndianapolis, Indiana
Chapter 27: Shock
MARY J. FAGAN, MSN, RNActing Vice President, Inpatient Services/Designated
Nurse ExecutiveChildren's Hospital, San DiegoSan Diego, California
Chapter 4: Leadership in Pediatric Critical Care
LORI D. FINEMAN, RN, MS
Clinical Nurse SpecialistPediatric Critical CareUniversity of California-San FranciscoSan Francisco, California
MARY Jo C. GRANT, PNP, PHDPediatric Critical Care Nurse Practitioner/
Nurse ResearcherPediatric Intensive Care UnitPrimary Children's Medical CenterSalt Lake City, Utah
Chapter 15: Host DefensesChapter 19: Pulmonary Critical Care Problems
LAUREN SORCE GREHN, RN, MSN, CCRN, CPNPPediatric Nurse PractitionerPediatric Critical CareChildren's Memorial HospitalChicago, lllinois
Chapter 21: Renal Critical Care Problems
TAMMARA L. JENKINS, MSN, RN, CCRNClinical Nurse Specialist, Pediatric Critical CareWarren G. Magnuson Clinical CenterNational Institutes of HealthBethesda, Maryland
Chapter 25: Oncologic Critical Care Problems
PATRICK KADILAK, RN, MSN, CNSClinical Nurse SpecialistPatient Care ServicesShriners Hospital for Children-BostonBoston, Massachusetts
Chapter 29: Thermal Injury
ANDREA M. KLINE, RN, MS, PCCNP, CCRNPediatric Critical Care Nurse PractitionerPediatric Intensive Care UnitChildren's Memorial Medical CenterChicago, Illinois
Chapter 21: Renal Critical Care Problems
x Contributors
DONNA M. KRAUS, PHA~~!D
Associate Professor of Pharmacy PracticePediatric Clinical PharmacistDepartments of Pharmacy Practice and PediatricsUniversity of Illinois at ChicagoChicago, Illinois
Chapter 13: Clinical Phannacology
PATRICIA M. LYBARGER, MSN, RNcClinical Information SpecialistPatient Care ServicesShriners Hospitals for Children-Bums HospitalBoston, Massachusetts
Chapter 29: Thermal Injury
AIMEE C. LYONS, RN, MSN, CCRNClinical Coordinator Multidisciplinary Intensive Care Unit
and PediatriclNeonatal Transport TeamDepartment of NursingChildren's Hospital, BostonBoston, Massachusetts
Chapter 31: Resuscitation and Transport of Infantsand Children
MAUREEN A. MADDEN, MSNPediatric Critical Care urse PractitionerDivision of Pediatric Critical CareInfants and Childrens Hospital of BrooklynMaimonides Medical CenterBrooklyn, New York
Chapter 30: Toxic Ingestions
EUGENE D. MARTIN, RN, MSAdvanced Education SpecialistNursing Education, Research and Program DevelopmentAll Children's HospitalSI. Petersburg, Florida
Chapter 5: Facilitation of Learning
SARA A. MARTIN, RN, MS, CPNP, PCCNP, CCRNPediatric Critical Care Nurse PractitionerPediatric Intensive Care UnitRush-Presbyterian-SI. Luke's Medical CenterChicago, Illinois
Chapter 2: Caring Practices: ProvidingDevelopmentally Supportive Care
ELAINE C. MEYER, PHD, RNStaff PsychologistChildren's Hospital of BostonAssistant Professor of PsychologyDepartment of PsychiatryHarvard Medical SchoolBoston, Massachusetts
Chapter 3: Caring Practices: The Impact ofthe Critical Care Experience on the Family
PATRICIA A. MOLONEy-HARMON, RN, MS, CCNS, CCRNAdvanced Practical Nurse/Clinical Nurse SpecialistThe Children's Hospital at SinaiBaltimore, Maryland
Chapter 24: Hematologic Critical Care ProblemsChapter 28: Trauma
PAULA MOYNIHAN, RN, BSN, CCRNClinical CoordinatorCardiovascular Intensive Care UnitChildren's HospitalBoston, Massachusetts
Chapter 18: Cardiovascular Critical Care Problems
LINDA OAKES, RN, MSN, CCRN, CCNSICUJPain Clinical Nurse SpecialistDepartment of NursingSI. Jude Children's Research HospitalMemphis, Tennessee
Chapter 17: Caring Practices: Providing Comfort
PATRICIA O'BRIEN, RN, MSN, PNPNurse PractitionerCardiovascular ProgramChildren's Hospital, BostonBoston, Massachusetts
Chapter 26: Organ Transplantation
MARY FRANCES D. PATE, DSN, RNClinical Nurse SpecialistPediatric Intensive Care UnitThe Children's Hospital of AlabamaBirmingham, Alabama
Chapter 14: Themwl Regulation
ANNPO\~~,MS,RN,CPNP
Pediatric Nurse PractitionerLong Pond Pediatrics and Osteopathy, P.C.Plymouth, Massachusetts
Chapter 9: Acid-Base Balance
SANDY QUIGLEY, MSN, CPNP, CETNClinical Nurse Specialist in Enterostomal TherapyPatient ServicesThe Children's HospitalBoston, Massachusetts
Chapter 16: Skin Integrity
KATHRYN E. ROBERTS, RN, MSN, CCRNClinical Nurse SpecialistPediatric Intensive Care UnitThe Children's Hospital of PhiladelphiaPhiladelphia, Pennsylvania
Chapter 11: Fluid and Electrolyte Regulation
CYNDA HYLTON RUSHTON, DNSc, RN, FAANAssistant Professor of Nursing; Clinical Nurse Specialist
in Ethics; Coordinator, Pediatric Palliative CareProgram; Faculty, Phoebe Berman Bioethics Institute
The Johns Hopkins University and Children's CenterBaltimore, Maryland
Chapter 6: Advocacy/Moral Agency: A Road Map forNavigating Ethical Issues in Pediatric Critical Care
GREGORY J. SCHEARS, MDAssistant Professor of Anesthesia and PediatricsDepartment of Anesthesia and Critical Care MedicineChildren's Hospital of Philadelphia, University
of PhiladelphiaPhiladelphia, Pennsylvania
Chapter 12: Nutrition Support
LYNN M. SEWARD, DIPLOMA
RN Coordinator7 South-TransplantsChildren's Hospital of PittsburghPittsburgh, Pennsylvania
Chapter 26: Organ Transplantation
SHARI L. SIMONE, RN, MS, CRNP, CCRNPediatric Critical Care Nurse PractitionerPediatric Intensive Care UnitUniversity of Maryland Medical SystemBaltimore, Maryland
Chapter 22: Gastrointestinal Critical Care Problems
PEGGY SLOTA, RN, MNDirector, Critical Care ServicesAdministrationChildren's Hospital of PittsburghPittsburgh, Pennsylvania
Chapter 26: Organ Transplantation
MARY FALLON SMtTH, RN, MSNClinical Nurse SpecialistEmergency DepartmentChildren's Hospital BostonBoston, Massachusetts
Chapter 31: Resuscitation and Transport of Infantsand Children
JANIS BLOEDEL SMITH, RN, MSNCase ManagerSystems Support ServicesVanderbilt University Medical CenterNashville, Tennessee
Chapter 2: Caring Practices: ProvidingDevelopmentally Supportive Care
Chapter 7: Tissue Perfusion
Contributors xi
KATHY L. SWARTZ, RN, MS, CCRNCare ManagerPediatric Intensive Care UnitChildren's HospitalColumbus, Ohio
Appendix
JOHN E. THOMPSON, RRTDirector of Clinical TechnologyChildren's HospitalAssociate in AnesthesiaDepartment of Respiratory CareHarvard Medical SchoolBoston, Massachusetts
Chapter 8: Oxygenation and Ventilation
TARA TRIMARCHI, MSN, RN, CRNPNurse PractitionerPediatric Intensive Care UnitThe Children's Hospital of PhiladelphiaLecturerUniversity of Pennsylvania, School of NursingPediatric Critical Care Nurse Practitioner ProgramPhiladelphia, Pennsylvania
Chapter 23: Endocrine Critical Care Problems
JUDY VERGER, RN, MSN, CCRNPediatric Nurse PractitionerPediatric Critical CareSchool of Nursing, University of PennsylvaniaThe Children's Hospital of PhiladelphiaPhiladelphia, Pennsylvania
Chapter 12: Nutrition Support
PAULA VERNON-LEVETT, MS, RN, CCRNStaff Nurse IIPediatric Intensive Care UnitUniversity of Iowa Hospitals & ClinicsIowa City, Iowa
Chapter 10: Intracranial DynamicsChapter 20: Neurologic Critical Care Problems
JOYCE WEISHAAR, RN, MSNClinical Nurse SpecialistPediatric Intensive Care UnitChildren's Memorial HospitalChicago, Illinois
Chapter 21: Renal Critical Care Problems
DARLENE E. WHITNEY, RN, BSN, CCRNStaff Nurse Level TwoPatient ServicesThe Children's HospitalBoston, Massachusetts
Chapter 16: Skin Integrity
FOREWORDThis publication of the second edition of Critical CareNursing of Infants and Children is another important milestone in the evolving development of pediatric critical carenursing. It often surprises students and colleagues when Idiscuss my experiences in the days "before pediatric intensive care units." They cannot conceive of a time whenthese specialized units, along with their highly technologictreatments, were not available to facilitate the care of critically ill children. During this "before" period, seriously illchildren were cared for on regular hospital units with minimal technology. Staff nurses were often assigned to "special" the child, unless the family provided a private dutynurse. Sometimes a separate room was set aside for care ofseveral seriously ill children so that one nurse could carefor several children. The level of expertise of these staffand private duty nurses, however, was not adequate for theintensive care needs of critically ill children. Obviouslychildren with serious health problems or children recovering from major surgery were at high risk of dying becauseadequate treatments and monitoring measures were notavailable.
The development of pediatric critical care units alongsidethe development of more-sophisticated treatments andrelated technology was highly effective in reducing themortality of acutely ill children. As these units developed, itsoon became obvious that the nurses working in these unitsneeded advanced training to adequately monitor and care forthese seriously ill children. It was essential that nurses haveaccess to the developing knowledge about critical care anddevelop the skills to apply that knowledge. Staff education,advanced critical care modules, and graduate educationwere some of the approaches used to prepare nurses for rolesin pediatric critical care. In addition, nurses themselvesbegan to become involved in the development of knowledgeabout critical care nursing through the conduct of nursingresearch and the synthesis and application of knowledgethrough the publication of clinical articles and textbooks.
The publication of Critical Care Nursing of Infants andChildren was another important step in the evolution ofnursing knowledge related to pediatric critical care. Thisstate-of-the-art textbook was unique in its strong nursingperspective, and the organization of the textbook was highlyinnovative. The first two sections provide a comprehensivebackground for the book, including a focus on historical,developmental, and family issues, as well as issues related tothe practice environment. This section has been improved
xiii
with a greater depth of information about development.Given the current complexities of treatment options in thePICU, the ethics section also has been expanded. The nextsection, on phenomena of concern, thoroughly covers themajor phenomena that pediatric critical care nurses mustdeal with on a daily basis. This content is then pulledtogether by focusing in depth on problems involving themajor body systems as well as multisystem problems. All ofthese sections have been updated to reflect current knowledge and practice.
The end result is a reference and teaching textbook thatprovides comprehensive and holistic content related to pediatric critical care nursing. Furthermore, the book has veryhigh standards for scholarship. Content is well validatedthrough reference to research and the latest clinical andtheoretical knowledge in the field. Putting this material together in an organized, cohesive, reader-friendly mannerwas truly a challenging and exciting endeavor.
Having watched and participated in the evolution of pediatric critical care nursing over the past 35 years, I am astounded at the knowledge explosion in the field and at thecomprehensive and complex scope of this specialty area ofnursing. To be a pediatric critical care nurse takes knowledge and skills in both the art and the science of nursing. Allnurses who take the step toward becoming pediatric criticalcare nurses should have a copy of this book to guide theirdevelopment as professionals in this exciting and everchallenging field. Nurses who are already experienced pediatric critical care nurses can gain new ways of conceptualizing their practice and will find the book extremely valuableas a resource in caring for challenging patients on theirunits. The text will also be invaluable for students enrolledin advanced practice pediatric graduate programs. Onewould hope that every pediatric intensive care unit in thecountry will have copies available for staff reference.
Critical Care Nursing of Infants and Children continuesto be a milestone in nursing textbooks because of itsexcellence and creativity. It serves as a model for futureapproaches in knowledge synthesis for practice. It certainlycan serve to strengthen the specialty of pediatric critical carenursing by providing a strong framework and backgroundfor practice.
MARGARET SHANDOR MILES, PhD, RN, FAANProfessor, School of Nursing
The University of North Carolina at Chapel Hill
PREFACECritical Care Nursing of Infants and Children is a state-ofthe-art textbook, written to provide a comprehensive reference for experienced nurses caring for critically ill pediatricpatients and their families. It is based on the broad clinicalexperiences of its contributors in the care of seriously ill orinjured children and in nursing research aimed at improvingand perfecting care. The strong nursing focus of this book isapparent in its structural approach-phenomena of concernandjinal common pathways. Phenomena of concern addressnursing care issues common to all critically ill pediatricpatients regardless of their primary problem. Final commonpathways cluster patient problems in such a way that allowsthem to be reframed from a perspective that guides nursingcare.
Pediatric critical care nursing has experienced extraordinary development since the advent of intensive care unitsdesigned specifically for the care of critically ill children.Nurses who care for critically ill infants and children arecontinuously challenged by diversity in patient age anddiagnosis. Skilled clinical practice requires knowledgeabout a wide variety of illnesses and injuries integrated withan awareness of the continuums of growth and development.Pediatric critical care nurses also require comprehensiveinformation about maturational anatomy and physiology,physical and psychosocial development, pathophysiologyand disease, critical instrumentation and patient management, and the most current pediatric critical care researchfindings.
The foundation for the text is provided in the chaptersthat detail children's and families' responses to the experiences of critical illness and intensive care, because thisaspect of pediatric critical care nursing is inherent to thepractice. Practical information supporting the evolving roleof the nurse as tender of the care milieu is unique. Chapterson nutrition, clinical pharmacology, thermal regulation, hostdefenses, skin integrity, and comfort management providehard-to-find, clinically relevant information specific for thecritically ill pediatric patient. A comprehensive review ofphysiology, with emphasis on the impact of maturation onsystem structure and function, is provided for each bodysystem. The pathophysiologic mechanisms, clinical manifestations' and diagnosis of disease in infants and childrenare presented in detail. Multisystem problems, includingoncology, organ transplantation, shock, trauma, thermalinjury, toxic ingestions, and resuscitation and transport, arepresented separately. Instrumentation appropriate to caringfor critically ill children and critical care managementof infants and children is discussed from a collaborativeframework. Appendixes are provided as a clinically usefulreference. A complete reference list is found at the end ofeach chapter, and tables and figures provide support to theentire text.
Critical Care Nursing of Infants and Children is dividedinto six sections that encompass all aspects of pediatriccritical care nursing.
Section I: Holistic Pediatric Critical Care Nursingpresents essential concepts that provide a foundation for thepractice of pediatric critical care nursing. The evolution
xv
of pediatric critical care nursing as a specialty is presented. Discussion of the impact of critical illness onchildren and families provides nurses with an appreciationof the magnitude of this experience and guides interventionsaimed at mitigating stress and promoting individual andfamily growth.
Section II: The Practice Environment focuses on themilieu affecting nursing care delivery. The broadening professional responsibilities of the nurse as leader, teacher,and mentor are acknowledged and supported. Ethical issues are illuminated from a pediatric critical care nursingperspective.
Section III: Phenomena of Concern focuses on theunique care needs of all pediatric patients regardless of theirprimary problem. Nurses playa major role in optimizing thepatient's potential outcome through a deliberative proactiveprocess that integrates skilled clinical knowledge abouttissue perfusion, oxygenation and ventilation, acid-basebalance, intracranial dynamics, fluid and electrolyte regulation, nutrition, clinical pharmacology, thermal regulation,host defenses, skin integrity, and comfort. Within eachphenomenon of concern, essential embryology, maturationalanatomy and physiology, and instrumentation are discussed.
Section IV: Final Common Pathways presents stateof-the-art nursing care for patient problems within eachbody system. A focus on the final common pathways ofmany disease states is presented so that system dysfunctionis viewed broadly and addressed within a nursing framework. For example, the numerous pathophysiologic statesthat result in increased intracranial pressure become similarto the nurse who is responsible for managing moment-tomoment changes in cerebral compliance in an effort toprevent secondary brain injury. The etiology, incidence, andpathogenesis of specific disorders that lead to developmentof a final common pathway are also presented when appropriate. Critical care management is focused on the finalcommon pathways of system dysfunction and specificallyon patient care unique to a particular disorder.
Section V: Multisystem Problems addresses theneeds of patients experiencing multiple system dysfunctionand their complicated demands and unique needs. Becausethese patients' illnesses involve more than a single bodysystem, they present a distinctive challenge to the care team.
Critical care nursing of infants and children is a dynamicspecialty necessitating nurses to ensure their practice isevidenced-based. Our goal in writing this text will berealized if readers are provided the knowledge they need toensure excellent care to critically ill children and theirfamilies. The goal of excellence in the critical care nursingof infants and children is based on commitment to childrenas our most precious resource and to families as the agentsof developing human potential. Also necessary is genuinerespect for the unique contributions of each member of themultidisciplinary team and for our nursing colleagues assources of immeasurable humanity and healing.
MARTHA A.Q. CURLEYPATRICIA A. MOLONEY-HARMON
ACKNOWLEDGMENTSWe express our gratitude to the clinical experts who are ourcontributors. The excellence of their work is evident in thepages that follow, in which they share the wealth of theirknowledge and expertise. We are grateful to our reviewers, who took the time and made the effort to commentconstructively and thoughtfully on the manuscript. We arealso grateful to the diligence of the research librarians andgraphic artists who either found or created the impossible.Finally, inspiration has always come from the children,families, and professionals with whom we have worked.Some of them may work with us still, perhaps others havea memory of some time or some experience we shared,others may be unaware that we carry their echoes with us.Thank you all.
We would also like to acknowledge the following contributors to the first edition of Critical Care Nursing ofInfants and Children. This second edition builds upon thesolid foundation their work provided.
Mary Allen Craig AlterJune Levine AriffM. Claire BeersAnne Milligan BrowneCheryl Cahill-AlsipElaine CaronSylvia Chin-CaplanChristine M. DickensonPatricia DillmanKathryn M. DoddsNeil EadE. Marsha ElixonArthur J. EnglerBarbara J. FewBarbara GillPeggy C. GordinDonna H. GrohNancy HagelgansTwila W. HarmonCarol J. HoweDiane S. JakobowskiKimmith M. Jones
Patricia Lawrence KaneLori J. KozlowskiMary Berry LeBoeufS. Jill LeyPatricia LincolnCathleen B. LongoWendy LudwigSusan Morgan MadderKimberly MasonBeth McDermottPamela M. MilbergerJoyce MolengraftRegina MuirKathryn M. MurphyKathleen M. OuztsSusan N. PeckWendy RobertsLinda F. SamsonClaire E. SommargrenJudith J. StellarMichele ToporKaren Zamberlan
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MARTHA A.Q. CURLEYPATRICIA A. MOLONEY-HARMON
CONTENTS
I Holistic Pediatric CriticalCare Nursing 1
1 The Essence of Pediatric CriticalCare Nursing 3
Martha A.Q. Curley
Evolution of the Discipline 3
Describing What Nurses Do: The Synergy Model 8
Current Environment 14
2 Caring Practices: ProvidingDevelopmentally Supportive Care 17
Janis Bloedel Smith, Sarah A. Martin
Conceptual Foundation for Caring Practice 17
The Infant (0 to 12 Months) 22
The Toddler (I to 3 Years) 28
The Preschooler (3 to 5 Years) 31
The School-Age Child 34
The Adolescent (12 to 21 Years) 37
The Chronically Critically III Child 41
Death in the Pediatric Intensive Care Unit 44
3 Caring Practices: The Impactof the Critical Care Experienceon the Family 47
Martha A.Q. Curley, Elaine C. Meyer
Evolution of Family-Centered Care Practices 47
Changing American Family Demographics 49
Basis for Intervention 49
Sources of Parental Stress 50
Identified Parental Needs and Coping Strategies 54
Intervention Strategies 56
Nursing Mutual Participation Model of Care 56
Family Context of Childhood Critical Illness 61
Preparing for Patient Transfer 63
Bereavement 63
Summary 64
II The PracticeEnvironment 69
4 Leadership in PediatricCritical Care 71
Mary J. Fagan
Current Challenges 71
Effective Leadership 72
Summary 82
xix
5 Facilitation of Learning 85Sandra Czerwinski, Eugene D. Martin
Recognizing Clinical Development 86Designing Staff Development Programs
for Professional Advancement 98Components of Staff Development 101
Summary 106
6 Advocacy and Moral Agency: A RoadMap for Navigating Ethical Issuesin Pediatric Critical Care 107
Cynda Hylton Rushton
What is Ethics? 108
Ethical Principles for Decision Making 108
Ethical Issues in Pediatric Critical Care 1/4
Decision-Making Models 117
Parents' and Children's Rights 1/9
Navigating Through Ethical Issues /2/
Summary /26
III Phenomenaof Concern 129
7 Tissue Perfusion 131Janet Craig, Janis Bloedel Smith, Lori D. Fineman
Essential Embryology 132
Essential Anatomy and Physiology 138
Physical Examination of the CardiovascularSystem 150
Noninvasive Evaluation and Diagnosis 155
Invasive Evaluation and Diagnosis /69
Pharmacologic Support of CardiovascularFunction /90
Manipulation of Ductal Patency and PulmonaryVascular Resistance 205
Pacemaker Therapy 209
Mechanical Support of Cardiovascular Function 215
Summary 226
8 Oxygenation and Ventilation 233Martha A.Q. Curley, John E. Thompson
Essential Embryology 234
Essential Anatomy and Physiology 236
Assessment of Pulmonary Functioning 251
Noninvasive Pulmonary Intensive CareMonitoring 256
Invasive Pulmonary Intensive Care Monitoring 262
Pulmonary Diagnostic Studies 264
Respiratory Support 266
Mechanical Support of Ventilation 282
xx Contents
Alternative Therapies 293
Summary 306
9 Acid-Base Balance 309Ann Powers
Definition of Acid-Base Balance 309
Regulation of Acid-Base Balance 310
Electrolytes and Acid-Base Balance 312
Maturational Factors 314
Analyzing Acid-Base Factors 314
Acid-Base Disturbances 3/4
Mixed Acid-Base Disorders 320
Summary 32/
10 Intracranial Dynamics 323Paula Vemon-Levetl
Essential Embryology 323
Essential Anatomy and Physiology 325
Intracranial Pressure Dynamics 340
Neurologic Assessment 343
Neurologic Intensive Care Monitoring 35/
Intracranial Pressure Monitoring 351
Monitoring Cerebral Function 356
Neurodiagnostic Studies 364
Summary 366
11 Fluid and Electrolyte Regulation 369Kathryn E. Roberts
Maturational Impact of Fluid and ElectrolyteRegulation 369
Assessment of Fluid and ElectrolyteBalance 37/
Monitoring Fluid and Electrolyte Balance 374
Support of Fluid and ElectrolyteRegulation 376
Alterations in Fluid Volume Balance 376
Electrolyte Disorders 382
Summary 39/
12 Nutrition Support 393Judy Verger, Greg Schears
Patient Response to Starvation and CriticalIllness 394
Nutrition Assessment 394
Nutrition Management 399
Summary 420
13 Clinical Pharmacology 425Donna M. Kraus
Pediatric Age Group Terminology 425
Monitoring Parameters 425
Pediatric Pharmacokinetics 425
Pharmacodynarrilcs 432
Medication Adrrilnistration in the PICU 435
Principles of Drug Interactions 441
14 Thermal Regulation 443Mary Frances D. Pate
Essential Physiology of TemperatureRegulation 444
Nursing Interventions to MaintainNormothermia 447
Abnormalities of Body TemperatureRegulation 450
Summary 457
15 Host Defenses 461Mary Jo c. Grant
Essential Embryology 461
Maturational Anatomy and Physiologyof the Immune System 462
Assessment of Immune Function 467
Diagnosing Dysfunction 480
Support of Immune Function 482
Alteration in Immune Function 491
Experimental Therapies 504
Summary 504
16 Skin Integrity 511Sandy M. Quigley, Dar/me E. Whitney
Integumentary Structure and Function 5/2
Phases of Wound Healing 5/2
Promoting Skin Integrity 5/5
Problems Encountered in Critical Care 518
Wound Care 535
Leech Therapy 543
Summary 544
t 1 Caring Practices:Providing Comfort 547
Linda L Oakes
Barriers to Effective Pain Managementin Children 548
Anatomy and Physiology 549
Children's Responses to Pain and Anxiety 551
Types of Pain 551
Pain Assessment 552
Assessment of Agitation 556
Nonpharmacologic Management of Painand Agitation 559
Pharmacologic Management of Painand Agitation 562
Nursing's Role in Pain Management 573
Summary 573
IV Final CommonPathways 577
t8 Cardiovascular CriticalCare Problems 579
Janet Craig, Lori D. Fineman, Paula Moynihan,Annette L Baker
Assessment of Patients with CardiovascularDysfunction 579
Final Common Pathways 580
Providing Baseline Support 580
Congestive Heart Failure 581
Cyanosis and Hypoxemia 587
Congenital Heart Disease 589
Perioperative Management of Pediatric CardiacSurgical Patients 620
Acquired Heart Disease in Infants and Children 629
Cardiac Rhythm Disturbances 640
Summary 651
t 9 Pulmonary Critical Care Problems 655Mary Jo C. Grant, Martha A.Q. Curley
Respiratory Failure 655
Mechanisms of Abnormal Gas Exchange 656
Final Common Pathways 656
Mechanical Alterations: Disorders That Increasethe Work of Breathing 658
Circulatory Alterations 686
Alterations in Control of Breathing 689
Summary 691
20 Neurologic Critical Care Problems 695Paula Vernon-Levett
Intracranial Hypertension 695
Status Epilepticus 703
Arteriovenous Malformation 705
Brain Tumors 707
Meningitis 709
Viral Encephalitis 7JJ
Hydrocephalus 712
Traumatic Brain Injury 714
Hypoxic Ischemic Encephalopathy 715
Near Drowning 719
Brain Death 722
Neuromuscular Disorders 723
Musculoskeletal Disorders 724
Summary 726
2 t Renal Critical Care Problems 731Louren Sorce Grehn, Andrea Kline, Joyce Weishaar
Embryologic Development of the Renal System 731
Maturational Factors 732
Acute Renal Failure 735
Contents xxi
Renal Replacement Therapy 749
Summary 763
22 Gastrointestinal CriticalCare Problems 765
Shari Simone
Embryology 765
Essential Anatomy and Physiology 766
Gastrointestinal Assessment 770
General Principles of Management 771
Gastrointestinal Obstruction 774
Gastrointestinal Inflammation 781
Gastrointestinal Bleeding 789
Abdominal Wall Defects 793
Hepatic Failure 794
Summary 801
23 Endocrine Critical CareProblems 805
Tara Trimarchi
Maturational Anatomy and Physiology 805
Disturbances of Water Balance: Fluid VolumeDeficit 807
Disturbances of Water Balance: Fluid VolumeExcess 809
Adrenocortical Hypofunction: Fluid Volume Deficitand Circulatory Failure 8JJ
Disturbances of Glucose Homeostasis 813
Summary 818
24 Hematologic CriticalCare Problems 821
Debbie Brinker, Patricia A. Moloney-Harmon
Essential Embryology 821
Essential Anatomy and Physiology 821
Assessment and Diagnosis of HematologicDisorders 827
Support of Hematologic Function 828
Disorders of Coagulation 835
Anemias 838
Mixed Disorders 844
Summary 849
V MultisystemProblems 851
25 Oncologic Critical Care Problems 853Tammara L Je1lkins
Care of the Neutropenic Patient 853
General Complications of Malignancy 1i54
Complications of Solid Tumors 862
Complications of Leukemic Disease 866
xxii Contents
Complications of Bone Marrow Transplantation 868
Summary 871
26 Organ Transplantation 875Peggy Slota, Lynn Seward, Patricia O'Brien,
Christine Angeletti
History 876
Current Challenges 876
Evaluation Process 877
Promotion of Graft Tolerance 879
Heart, Heart-Lung, and Lung Transplantation 890
Liver Transplantation 900
Intestine and Multivisceral Transplantation 907
Kidney Transplantation 910
Pancreas and Islet Cell Transplantation 915Quality of Life and Follow-Up Care Issues 916
27 Shock 921Cathy H. Dichter, Martha A.Q. Curley
Categories of Shock 926
Trajectory of IJIness 926
Physiologic Responses to Shock 926
Clinical Assessment: Red Flags of CardiovascularCollapse 930
Collaborative Management 933
Proactive Care: Vigilance 940
Unconventional Therapies 942
Summary 943
28 Trauma 947Patricia A. Moloney-Harmon, Patricia Adams
Initial Resuscitation 948
Trauma Scores 950
System-Specific Injuries 951
Priorities for Multiple Trauma 973
Child Maltreatment 974
Summary 977
29 Thermal Injury 981Patricia M. Lybarger, Patrick Kadilak
Etiology of Pediatric Burn Injuries 981
Pathophysiology 982
Injury Types 983
Critical Care Management 988
Burn Outcomes 996
Summary 996
30 Toxic Ingestions 999Maureen A. Madden
Common Principles of Emergency and Critical CareManagement 1000
Pharmaceutical Toxins 1004
Nonpharmaceutical Toxins-The Alcoholsand Drugs of Abuse 1014
Household Toxins 1020
Summary 1022
31 Resuscitation and Transport of Infantsand Children 1025
Mary Fallon Smith, Aimee Lyons
Epidemiology of Cardiopulmonary Arrestin Children 1025
Etiology of Cardiopulmonary Arrest 1025
Red Flags of Impending CardiopulmonaryArrest 1026
Strategies for Prevention of CardiopulmonaryArrest 1027
Collaborative Management 1028
Postresuscitation Management 1041
Interfacility Transport 1043
Resuscitation Performance Improvement 1051
Summary 1052
AppendixesCompiled by Kathy Swartz
Appendix I Normal Blood Pressure 1055
AppendIx II Growth Charts 1057
Appendix III Normal ImmunizationSchedule 1067
AppendIx IV Emergency Cart Contents 1069
AppendIx V Drug Compatibility Chart 1073
Appendix VI Critical Care Registered Nurse(CCRN) Certification ExaminationBlueprint-Pediatric Program
1077
AppendIx VII Multidisciplinary ICU, Children'sHospital, Boston, Clinical PracticeGuideline Enteral NutritionSupport 1079
AppendIx VIII Children's Hospital NeonataI/Pediatric Transport DataBase 1085
